1.
Combining E&M and Psychotherapy Codes on a single encounter

I do not use time for the E&M code, but rather it is based on the required number of elements for a given E&M code. For example:

I see a patient for a follow-up visit. The patient has both Bipolar Disorder Type I MRE Depressed, Hypertension, and Fibromyalgia. I include short supportive psychotherapy for about 16 minutes and use code 90832 (16 - 30 minutes pf psychotherapy) plus a review of vital signs, review of systems (at least 3 systems) and note the patient's progress with medication and focused areas related to her illnesses. I add the 99213 E&M code (moderate complexity). To deal with the time factor (for psychotherapy) I note the start time and the end time of the encounter in the progress note. For this encounter the start time is 2:59 PM and the stop time is 3:30. Then at the end of the progress note I document "I spent 16 minutes of 31 minutes providing supportive psychotherapy focused on ________. This way for auditors, it is clear that 16 minutes (the minimum for 90832) of the encounter was devoted to psychotherapy. The elements to justify the E&M coding are documented, as well. This has proven (so far) to be acceptable to our auditors.

I do not use time for the E&M code, but rather it is based on the required number of elements for a given E&M code. For example:

I see a patient for a follow-up visit. The patient has both Bipolar Disorder Type I MRE Depressed, Hypertension, and Fibromyalgia. I include short supportive psychotherapy for about 16 minutes and use code 90832 (16 - 30 minutes pf psychotherapy) plus a review of vital signs, review of systems (at least 3 systems) and note the patient's progress with medication and focused areas related to her illnesses. I add the 99213 E&M code (moderate complexity). To deal with the time factor (for psychotherapy) I note the start time and the end time of the encounter in the progress note. For this encounter the start time is 2:59 PM and the stop time is 3:30. Then at the end of the progress note I document "I spent 16 minutes of 31 minutes providing supportive psychotherapy focused on ________. This way for auditors, it is clear that 16 minutes (the minimum for 90832) of the encounter was devoted to psychotherapy. The elements to justify the E&M coding are documented, as well. This has proven (so far) to be acceptable to our auditors.